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Protecting People With Special Needs from the Dangers of Caregiver Fatigue

The NYS Justice Center for the Protection of People with Special Needs (Justice Center) is committed to supporting and protecting the health, safety and dignity of people with special needs and disabilities. The Justice Center has launched a series of toolkits which provide facts, best practices and resources that can be used by everyone who has a vested interest in preserving the safety and well-being of individuals who receive services or supports.

Falling asleep on the job puts caregivers at risk of making mistakes that could endanger adults and children who may require consistent and responsive attention to ensure their health and safety. The Justice Center’s 24-hour abuse and neglect hotline has received numerous reports of incidents involving staff inattention to their duties and poor decision-making resulting from sleep deprivation, workplace fatigue or sleeping during a shift.

Whether you are an individual, self-advocate, direct care provider, agency administrator, friend or family member — you have an important role to play in preventing a needless tragedy from happening. The information provided in this toolkit will help raise awareness of the seriousconsequences of caregiver fatigue and falling asleep on duty. It also includes simple safety practices to reduce the risks linked to this serious safety hazard. A printable copy of this toolkit can be found at the bottom of this page.

The Risks

Caregiver inattention may result in an incident that jeopardizes the safety and well-being of people receiving services.This could include:

An individual’s personal care and health needs not being met;

Failure to prevent or de-escalate an individual’s high-risk behaviors, such as choking or elopement;

Inability to respond to an individual’s acute medical needs; and/or

Failure to respond to an emergency, such as a fire.

FROM OUR CASE FILES

The case studies in this toolkit involve fictitious victims and represent a collection of facts identified from multiple investigations and are used for illustrative purposes only.

CASE 1: Inattention to a resident’s acute medical need and a seizure in progress

A case of staff complicity and failure to communicate with the administrator on-duty, willful sleeping due to illness + co-worker sympathy or detachment.

Joseph works the day shift at a community residence for individuals with developmental disabilities. He observed co-worker Jessica lying on the living room couch, facing away from view of resident Sierra who was sitting in her wheelchair quietly watching television. Joseph proceeded to the kitchen to start making breakfast without advising Jessica because he knew that she did not feel well. While in the kitchen, Joseph heard a loud noise coming from the living room and rushed to see what was going on. He found Jessica fast asleep as Sierra was having a grand-mal seizure. Jessica failed to adhere to Sierra’s safety plan for her seizure disorder, which includes continuous one-to-one monitoring. Staff must also notify 9-1-1 if a seizure lasts more than four minutes or if Sierra turns blue.

Joseph quickly responded by observing Sierra’s airway and coloring and timed the length of her seizure. He stayed with Sierra until after the seizure was over and she appeared to be okay. He then documented the incident and notified the nurse before heading back to the kitchen.

About mid-morning, Jessica told Joseph that she was very sick and went home early. Joseph worked alone until another staff member arrived a half-hour later. Neither Joseph, nor Jessica reported to the administrator-on-duty that Jessica was unfit for duty all morning due to illness or that she needed to leave early.

James, an administrator made an unannounced visit to the Miller Road residence at 5 a.m. The facility, which provides services for individuals with mental illness, is routinely staffed with two full-time awake care staff between the hours of 10 p.m. and 8 a.m. When James arrived, he found both staff members asleep in the living room. An alarm clock next to a couch was found to be set for 5:45 a.m. Dining room chairs had been placed outside of the bedroom doors and in front of the kitchen entrance in what appeared to be barricades. When James approached the kitchen, he discovered a chair had been pushed slightly aside and resident Jay eating peanut butter from a jar with a spoon. Jay was supposed to never be left alone in the kitchen because he has a history of unsafely consuming food, which puts him at risk of choking.

A case of a non-traditional/long shift + use of prescribed medications affecting alertness + no emergency staffing plan to relieve staff who are unfit for duty.

One Fall Saturday afternoon, individuals receiving services at a community residence for drug and alcohol treatment noticed that Michelle, the only staff person on duty, appeared to be “groggy” and possibly under the influence of drugs. They became concerned when she failed to administer their scheduled medications. They tried, but were unable to rouse Michelle when they found her slumped over and asleep in the medication room. One resident opened the unlocked medication cabinet and helped three others retrieve their medication from labeled drawers before Michelle woke up. Michelle’s work schedule includes an “on-call” shift on Thursdays. She is the only staff person on duty from Friday at 5 p.m. until Monday at 3:00 p.m. Michelle is permitted to sleep during the overnight shift, barring any need that may arise to provide assistance to individuals during those hours.

On the afternoon of the incident, Michelle called the program administrator and asked to be relieved of her duties after taking a prescribed medication. The administrator, who was either unable or unwilling to grant Michelle’s request failed to send anyone to relieve her. Michelle recalled feeling dizzy around 7 p.m. and sat down in a chair. She said she was later awakened by a resident who told her that while she had been sleeping the residents had gained access to their medications.

CASE 4: A motor vehicle accident

A case of a non-traditional/long work shift (17-hour shift followed by a 12-hour shift) + a new medication affecting alertness + a staffing assignment to transport residents.

It was a beautiful summer afternoon when Zoraya, who works the day shift at a residence for individuals with developmental disabilities, offered to take six residents to the local county fair. The group arrived at the fair around 4 p.m. and spent a few hours walking around, eating food and playing games. During the drive back to the residence, Zoraya fell asleep at the wheel, drove off the road, and crashed into a utility pole. The impact of the collision woke Zoraya, at which time she immediately checked on the status of all of her passengers who all reported being okay. Zoraya reported the accident to her supervisors as she was required to do.

Zoraya’s work schedule often varied throughout the week. Her shifts ran 8 to 17 hours, averaging a 42-hour work week. The day prior to the accident, Zoraya had worked a 17-hour shift and then reported back to work approximately eight hours later for a 2-hour shift. When interviewed about the accident, Zoraya confirmed that she had lacked sleep and was exhausted. She admitted that she caught herself dozing off during the drive back to the residence. Zoraya also revealed she had been taking a new medication with a side effect that could affect alertness and included a caution against driving. Zoraya neglected to inform her supervisor of her medication regimen, as it might affect her driving responsibilities, as she was required to do under the agency’s “Vehicle Use” policy.

Jeremy has worked the night shift at the same youth residential facility for almost seven years. During this time, he has become close friends with the other night shift staff. His co-workers were aware that Jeremy works two jobs. At around 11 p.m. each night, Jeremy routinely dozes off for a few hours. After taking his “power nap,” he gets up and completes the rest of his nightly duties. One night at around 2 a.m., Jeremy awoke and resumed his scheduled bed check responsibility, when he noted resident Caleb was missing from his bedroom. Staff members found a bed sheet had been tied around a fixed object that led out the window.

Police ultimately located Caleb at a family member's residence. Caleb later reported he stayed up late several nights to prepare for his escape, after he discovered scheduled bed checks were not performed until around 2 a.m. On the night he eloped, Caleb waited until 11:30 p.m. and then quickly fled the residence, expecting this would give him about two hours before anyone would notice he was gone. When questioned, the other night staff acknowledged they were aware of Jeremy’s habits. And though unaware of his exact responsibilities—they believed he did a good job overall, and didn’t see any harm in him taking a few hours to rest. His supervisor had suspected Jeremy may be sleeping on the job, but when asked previously, other staff had denied it and the supervisor had not been able to perform surprise “spot checks” as planned to confirm Jeremy’s sleeping habit.

LESSONS LEARNED

➢Unexamined Risk Factors—Many incidents involved staff working extended or otherwise non-traditional work shifts. Identifiable risk factors included reporting to work when their ability to work was questionable, or they were unfit for duty due to an illness, exhaustion or the side-effects of prescribed medications. These risk factors often do not appear to have been considered in agency remediation plans.

➢Indiscriminate Polices for Addressing Willful and Accidental Acts of Sleeping on the Job—Agencies often addressed both willful acts of sleeping and accidental nodding-off with the same approaches. Most incident investigation and review activities failed to adequately consider the unique risk profiles and the circumstances of individual staff and events when determining staff penalties or other plans for corrective action.

➢Ineffective Deterrents—Agencies where staff were found sleeping routinely had strong policies in place that are meant to deter workplace sleeping. Most agencies imposed random administrative spot checks and rigorously addressed all acts of confirmed staff sleeping with penalties associated with neglect, misconduct or other dereliction of duty. Yet, incidents of staff sleeping on duty continue to occur, even at agencies with strategies in place.

➢Disempowered Individuals Receiving Services—Individuals receiving in-patient or residential care who discovered that their solitary caregiver (or in some cases, all of their caregivers on duty) was sleeping or was otherwise incapacitated, did not regularly take any action. It appeared that these service-recipients had not been taught or empowered to take action to bring attention to unsafe conditions or emergencies. Further, when they were questioned about specific incidents of alleged staff sleeping— they often disclosed previous unreported complaints of staff sleeping.

➢New Prevention Strategies Are Needed-- Strategies to detect and deter caregiver fatigue and sleeping on the job must:

•plan for identifiable staff risk factors;

•discriminate between risks of willful and accidental sleeping on the job;

•utilize effective deterrents for each type of hazard; and

•empower service recipient to recognize unsafe conditions and seek out help in emergencies and other unsafe situations.

This prevention tool kit contains a sample Staff Personal Action Plan as an example of a strategy that could be used to help a caregiver and his or her supervisor in the assessment of, and in planning for mitigating risks, associated with accidental caregiver sleeping on the job.

Completing a plan like this one could also serve as an opportunity to reinforce with a caregiver the agency’s expectations of caregiver alertness and attention to safety, and that there are strict penalties for unauthorized sleeping on the job.

This tool kit also provides a sample Personal Safety Plan for an Individual Receiving Services as an example of a potential strategy that could be used to help in the development of a plan to teach and reinforce resident/patient safety skills.

ADDITIONAL RESOURCES:

Spotlight on Prevention Toolkit: Protecting People with Special Needs from the Dangers of Caregiver Fatigue

Article

Fact Sheets for Individuals, Provider Agencies and staff

Checklist

How to Make a Staff Action Plan to Identify and Address Risks of Dangerous Caregiver Fatigue